Health care workers must always protect themselves first. The use of appropriate personal protective equipment, appropriate patient isolation, and handwashing when dealing with any patient will protect against most biological agents (Table 56.3).21 It is important for health care workers to maintain a healthy lifestyle that includes current immunization status (e.g., tetanus, diphtheria, influenza vaccine, polio). In the event of an exposure secondary to caring for victims of a biologic incident, rapid postexposure treatment (prophylactic medications or vaccinations) must be started.
Response
Universal precautions are important for good infection control. The simplest and most effective practice a nurse can have to reduce contamination and spread infection is handwashing. Personal protective equipment (e.g., gown, mask, gloves, hair cover) should be used if an infectious disease is suspected.21 This is true for any potentially infectious disease or a patient contaminated with a biologic agent associated with terrorism.13
Decontamination of the patient may be required. If the biologic attack is overt, decontamination should occur. Removing all clothes and sealing them in a plastic bag as well as a shower with soap and large amounts of water are important to dilute and remove biologic agents. Bleach kills the anthrax spores on clothes and objects, but it should not be used on skin. In the event of a covert attack, decontamination is less of an issue because of the time from exposure. The medical facility should quickly attempt to make a presumptive diagnosis and not delay treatment awaiting complete test results. The Emergency Operations Center of the CDC should be notified, and treatment should begin immediately. Empiric treatment of respiratory casualties should not be delayed because early intervention is most effective.
Patient treatment should follow the advanced trauma life support protocol, concentrating on airway, breathing, and circulation. New best practice guidelines recommend using the Surviving Sepsis Campaign model for improvement of care using bundles.22 A bundle is a group of therapies that, when implemented together, may result in better outcomes for patients with sepsis than if implemented individually. The individual components included in a bundle are built around best evidence-based practices. Use of the Severe Sepsis Bundles can achieve a 25% reduction in mortality due to severe sepsis or septic shock.22 See the Evidence-Based Practice Box and Chapter 55.
As seen in Table 56.2, bacterial infections can lead to sepsis quickly, especially anthrax, tularemia, pneumonic plague. Through evidence-based recommendations for sepsis management and treatment, rapid and clearly articulated strategies help to reduce negative outcomes from sepsis. The intention is to apply the bundles 100% of the time within the first 6 hours of identification of severe sepsis.22
Isolation for patients can present a problem. Gathering patients with similar symptoms into a separate room or area of a room and separating the infected persons from postoperative patients solves the problem of isolation needs. Manipulation of ventilation and air pressure within smoke compartments can provide a solution for negative pressure rooms. Knowledge of the specific requirements for different biological agents is necessary. See Table 56.2 for specific requirements for each agent.21
In the event of a death, the body of the deceased will need to be used as evidence and cannot be released to the mortuary without approval from local law enforcement.
Communication
Plans for a rapid response to bioterrorism must be communicated to the community at the local, state, and national levels. The PACU must evaluate and define their roles in a bioterrorism event. Communication must exist between the administration, management, and staff members to identify training, staffing, and supply needs to be adequately prepared to respond and meet the challenge of bioterrorism events.
The psychological aspects of terrorism must be anticipated and communicated. Expected responses for health care workers, patients, and their families can include horror, anger, panic, and unrealistic fears about infection, fear of contagion, and social isolation. When developing a facility emergency plan, the following should be addressed: rapid availability of medical evaluation and treatment to reduce panic; availability of educational materials for the public; availability of mental health support personnel for staff members, patients, and families; and provision of care for persons experiencing psychosomatic symptoms.
Evidence-Based Practice
The Surviving Sepsis Campaign is the result of an international program for the development of guidelines for early intervention and treatment of severe sepsis. The guidelines have been updated, most recently in 2012, by critical care and infectious disease experts from international organizations. Consensus guidelines are developed after careful evaluation and grading of the existing literature, followed by a group consensus, and the guidelines are presented with an indication of the level of evidence for each recommendation. Many of the recommendations continue to have relatively weak evidence, but the panel of experts agrees that a reasonable person would evaluate the risk versus benefit and would choose the treatment. The definitions of septic shock and severe sepsis are important because the distinction guides clinical decision making.
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